Sudeep Das De

Biventricular assist devices (BiVADs) using the CentriMag™ system are being used increasingly as a form of short-term mechanical circulatory support for the treatment of acute cardiogenic shock from any aetiology. They can be used as a bridge to decision, recovery or transplantation. BiVADs are associated with better clinical outcomes when compared to veno-arterial (VA) extracorporeal membrane oxygenator (ECMO) systems. In this paper, we describe a safe and reproducible method of BiVAD implantation using the CentriMag™ system at our institution.

Infective endocarditis carries a heavy disease burden with a high in-patient mortality. Surgery is the mainstay of treatment in 50% of patients diagnosed with infective endocarditis. Surgery for infective endocarditis can be challenging; a detailed understanding of surgical anatomy is essential and several fundamental principles need to be taken into consideration including optimal timing, radical debridement, decision to repair versus replace as well as the optimal choice for reconstruction. Outcomes of surgery depend on several factors including patient characteristics, the valve (s) involved, the virulence of the organism, and the extent of invasion of the infective process. Despite recent advances in treatment and improved outcomes, there remains areas for potential research including the ideal valve prosthesis/substitute and the optimal material for reconstruction. In this chapter, we will discuss the technical challenges and pitfalls in the surgical treatment of infective endocarditis, the predictors of outcome as well as novel strategies in treatment.

OBJECTIVES: To evaluate the use of CABG utilising an isolated pedicled Right Internal Thoracic Artery (RITA) or Left Internal Thoracic Artery (LITA) or the Pure Internal Thoracic Artery (PITA) technique to treat anomalous aortic origin of coronary artery (AAOCA). METHODS: A retrospective review of all patients at our institution over an 8-year period (2013–2021) who underwent surgery for AAOCA was performed. Data assessed included patient demographics, initial presentation, morphology of coronary anomaly, surgical procedure, cross-clamp time, cardiopulmonary bypass time, and long-term outcome. RESULTS: A total of 14 patients underwent surgery, including 11 males (78.5%) with a median logistic EuroSCORE of 1.605 (IQR 1.34). The median age was 62.5 years (IQR 48.75). Presentation was angina (7 patients), acute coronary syndrome (5 patients), incidental findings in aortic valve pathology (2 patients). AAOCA morphology varied: RCA from left coronary sinus (6), RCA from left main stem (3), left coronary artery from the right coronary sinus (1), left main stem arising from right coronary sinus (2) and circumflex artery arising from the right coronary sinus (2). Overall, 7 patients had co-existing flow-limiting coronary artery disease. CABG was performed using either a pedicled skeletonized RITA, LITA or PITA technique. There was no perioperative mortality. Overall median follow-up time was 43 months. One patient presented with recurrent angina secondary to graft failure at 2 years and there were two non-cardiac-related deaths at 4 and 35 months. CONCLUSION: The use of internal thoracic artery grafts can provide a durable treatment option in patients with anomalous coronary arteries. The potential risk of graft failure in patients with no flow-limiting disease should be very carefully considered. However, a proposed benefit of this technique is the use of a pedicle flow to increase the long-term patency. More consistent results are obtained when ischaemia can be demonstrated preoperatively.

The evidence on the impact of patient-prosthesis Mismatch (PPM) on survival thus far has been conflicting. The aim of this study was to 1) study the effect of PPM on survival after isolated aortic and mitral valve replacement and 2) Assess the interaction between left ventricular function and PPM on survival. The study cohort was patients who underwent isolated Aortic valve replacement (AVR) and Mitral valve replacement (MVR) over a 10-year period from 2008 to 2018. PPM was defined using the projected indexed effective orifice area (EOAi). The cohort was divided into different groups based on the degree of PPM. The severity of PPM was classified using threshold values of EOAi used in the literature. The Kaplan- Meier method was used to compare survival by degree of PPM. Multivariate Cox proportional hazards models were used to generate adjusted hazard ratios (HR) with 95% confidence intervals. An interactive term for ejection fraction (EF) was added to test whether EF modifies the effect of the PPM grade on survival. In addition, sub-group analysis based on left ventricular function was performed. In the AVR cohort, there were a total of 1953 patients. The distribution of patients in the different PPM categories was as follows: no PPM 59.7%; moderate PPM 36.8%; severe PPM 3.5%. There was no significant difference in survival between the different groups. At 10 years, the adjusted HR between patients with severe PPM versus no PPM was 1.1(CI 0.5–2.4, p > 0.05) and the HR between those with moderate PPM versus no PPM was 0.97 (CI 0.74–1.23, p > 0.05). In the MVR cohort, there were a total of 298 patients. The distribution of PPM is as follows: no PPM 59.4%; and with PPM 40.6%. Again, there was no significant difference in survival between the groups. At 5 years, the adjusted HR between patients with PPM versus no PPM was 1.45 (CI 0.67–3.14, p > 0.05). In both groups, there was no significant interaction between left ventricular function (LVF) and degree of PPM on survival. In our study cohort, the degree of PPM was not an independent predictor of survival after AVR or MVR. There was also no significant interaction between LV function and degree of PPM on survival.

The British Transplantation Society states that previous chest surgery in a donor constitutes a contraindication to lung retrieval. In this report, we describe a case of successful bilateral lung harvest from a donor who had previously undergone aortic valve replacement. This case highlights that isolated valve surgery can be an addition to the extended donor criteria for lung retrieval and therefore increase the number of organs available for transplantation.

We report a case of a 41-year-old Indian man who initially underwent an emergency coronary artery bypass grafting surgery (CABG) after presenting with an anterolateral myocardial infarction.